Nasal high flow therapy introduction lowers reintubation risk in a Peruvian paediatric intensive care unit.

AIM: We examined the impact of introducing high-flow nasal oxygen therapy (HFNT) on children under five with post-extubation respiratory failure in a paediatric intensive care unit (PICU) in Peru. METHODS: This quasi-experimental study compared clinical outcomes before and after initial HFNT deployment in the PICU at Instituto Nacional de Salud del Niño in Lima in June 2016. We compared three groups: 29 received post-extubation HFNT and 17 received continuous positive airway pressure (CPAP) from 2016-17 and 12 historical controls received CPAP from 2012-16. The primary outcome was the need for mechanical ventilation. Adjusted hazard ratios (aHR) and 95% confidence intervals (95% CI) were calculated via survival analysis. RESULTS: High-flow nasal oxygen therapy and CPAP did not alter the need for mechanical ventilation after extubation (aHR 0.47, 95% CI 0.15-1.48 and 0.96, 95% CI 0.35-2.62, respectively) but did reduce the risk of reintubation (aHR 0.18, 95% CI 0.06-0.57 and 0.14, 95% CI 0.03-0.72, respectively). PICU length of stay was 11, 18 and 37 days for CPAP, HFNT and historical CPAP and mortality was 12%, 7% and 27%, respectively. There was no effect on the duration of sedative infusions. CONCLUSION: High-flow nasal oxygen therapy provided effective support for some children, but larger studies in resource-constrained settings are needed.

Sustainability of high flow in a Peruvian PICU: A qualitative analysis.

AIM: To describe nurse and physician perspectives on enabling factors that promote sustainability of high flow use in resource-limited settings. BACKGROUND: Over 650 000 children died from respiratory infections in 2016 globally. Many deaths could be prevented with access to advanced paediatric respiratory support, but sustainability of technology in resource-limited settings remains challenging. INTRODUCTION: Local providers have expertise related to site-specific barriers to sustainability. Engaging local providers during implementation can identify strategies to promote ongoing technology use beyond initial deployment. METHODS: This qualitative descriptive study was conducted five focus groups with nineteen nurses and seven individual interviews with physicians in a Peruvian paediatric intensive care unit. Data were analysed using a realist thematic approach. RESULTS: Providers described five important factors for high flow sustainability: (i) Applying high flow to a broader patient population, including use outside the paediatric intensive care unit to increase opportunities for practice; (ii) Establishing a multidisciplinary approach to high flow management at all hours; (iii) Willingness of nurses and physicians to adopt standardization; (iv) Ongoing high flow leadership; (v) Transparency of high flow impact, including frequent reporting of clinical outcomes of high flow patients. DISCUSSION: Local providers described strategies to overcome barriers to sustainability of high flow in their clinical setting, many of which are generalizable to implementation projects in other resource-limited settings. CONCLUSION AND POLICY IMPLICATIONS: These findings provide nursing, administrative leaders and policymakers with strategies to promote sustainability of new technology in resource-limited settings, including development of guidelines for appropriate clinical use, change management support, leadership development and clinical outcome reporting procedures. Administrative support and oversight are paramount to foster successful implementation in these settings.

Key considerations prior to nasal high flow deployment in a Peruvian PICU from providers' perspectives.

AIM: Implementation of healthcare interventions in resource-limited settings remains challenging. This exploratory qualitative study describes social and institutional factors to consider prior to nasal high flow deployment in a middle-income country. METHODS: Researchers conducted eight nursing focus groups and four semi-structured physician interviews at Instituto Nacional de Salud del Niño in Lima, Peru. Participants were identified via purposive sampling. Data were transcribed, translated and coded using a rigorous and iterative process. Pertinent themes were identified using thematic analysis with Dedoose software. RESULTS: Thirty-nine nurses and four physicians participated in focus groups and interviews, respectively. Participants identified five major factors: (i) Adequate training, (ii) Clinician buy-in, (iii) Resource-limited setting, (iv) Local social context and (v) Organizational change management. To create buy-in, physicians and nurses emphasised the need to recognise benefit of the intervention and agree with clinical practice standardization. Physicians and nurses described barriers specific to resource-limited settings, including unreliable supply chain, whereas nurses shared concerns about increasing workload and physician-nurse social hierarchy. Participants recognised the importance of team commitment and ongoing interdisciplinary communication for sustainability. CONCLUSION: While some factors to consider prior to deployment of healthcare technology are universal, resource-limited settings have unique implementation barriers.

Emergency department risk factors for serious clinical deterioration in a paediatric hospital in Peru.

AIM: Identification of critically ill children upon presentation to the emergency department (ED) is challenging, especially when resources are limited. The objective of this study was to identify ED risk factors associated with serious clinical deterioration (SCD) during hospitalisation in a resource-limited setting. METHODS: A retrospective case-control study of children less than 18 years of age presenting to the ED in a large, freestanding children's hospital in Peru was performed. Cases had SCD during the first 7 days of hospitalisation whereas controls did not. Information collected during initial ED evaluation was used to identify risk factors for SCD. RESULTS: A total of 120 cases and 974 controls were included. In univariate analysis, young age, residence outside Lima, evaluation at another facility prior to ED presentation, congenital malformations, abnormal neurologic baseline, co-morbidities and a prior paediatric intensive care unit admission were associated with SCD. In multivariate analysis, age < 12 months, residence outside Lima and evaluation at another facility prior to ED presentation remained associated with SCD. In addition, comatose neurological status, hypoxaemia, tachycardia, tachypnoea and temperature were also associated with SCD. CONCLUSIONS: Many risk factors for SCD during hospitalisation can be identified upon presentation to the ED. Using these factors to adjust monitoring during and after the ED stay has the potential to decrease SCD events. Further studies are needed to determine whether this holds true in other resource-limited settings.

Knowledge acquisition and retention after a high flow training programme in Peru: a quasi-experimental single group pre-post design.

OBJECTIVE: Respiratory infections remain the leading infectious cause of death in children under 5 and disproportionately affect children in resource-limited settings. Implementing non-invasive respiratory support can reduce respiratory-related mortality. However, maintaining competency after deployment can be difficult. Our objective was to evaluate the effectiveness of a comprehensive multidisciplinary high-flow training programme in a Peruvian paediatric intensive care unit (PICU). DESIGN: Quasi-experimental single group pre-post intervention study design. SETTING: Quaternary care PICU in a resource-constrained setting in Lima, Peru. PARTICIPANTS: Attending physicians, fellows, paediatric residents, registered nurses, respiratory therapists and medical technicians working in the PICU were invited to participate. INTERVENTIONS: Concurrent with initial high-flow deployment, we implemented a training programme consisting of lectures, case-based discussion and demonstrations with baseline, 3-month and 12-month training sessions. Pre-training and post-training assessment surveys were distributed surrounding all training sessions. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome was achieving minimum competency (median score of 80%) on the high flow training assessment tool. Secondary outcomes included knowledge acquisition (differences in pre-baseline and post-baseline training assessments), short-term retention (differences in post-baseline and pre-3-month refresher training assessments) and long-term retention (differences in post-3-month refresher and pre-12-month refresher training assessments). RESULTS: Eighty participants (50% nurses, 15% ICU physicians and 34% other providers) completed the baseline assessment. Participants showed improvement in overall score and all subtopics except the clinical application of knowledge after baseline training (p<0.001). Participants failed to retain minimum competency at 3-month and 12-month follow-up assessments (70% (IQR: 57-74) and 70% (IQR: 65-74), respectively). After repeat training sessions, overall knowledge continued to improve, exceeding baseline performance (78% (IQR: 70-87), 83% (IQR: 74-87) and 87% (IQR: 83-91) at baseline, 3 and 12 months, respectively). CONCLUSION: This study suggests the need for repeat training sessions to achieve and maintain competency after the implementation of new technology.

Successful Deployment of High Flow Nasal Cannula in a Peruvian Pediatric Intensive Care Unit Using Implementation Science-Lessons Learned.

Acute lower respiratory infections are the leading cause of death outside the neonatal period for children less than 5 years of age. Widespread availability of invasive and non-invasive mechanical ventilation in resource-rich settings has reduced mortality rates; however, these technologies are not always available in many low- and middle-income countries due to the high cost and trained personnel required to implement and sustain their use. High flow nasal cannula (HFNC) is a form of non-invasive respiratory support with growing evidence for use in pediatric respiratory failure. Its simple interface makes utilization in resource-limited settings appealing, although widespread implementation in these settings lags behind resource-rich settings. Implementation science is an emerging field dedicated to closing the know-do gap by incorporating evidence-based interventions into routine care, and its principles have guided the scaling up of many global health interventions. In 2016, we introduced HFNC use for respiratory failure in a pediatric intensive care unit in Lima, Peru using implementation science methodology. Here, we review our experience in the context of the principles of implementation science to serve as a guide for others considering HFNC implementation in resource-limited settings.

Prácticas de soporte nutricional en unidad de cuidados intensivos pediátrica

RESUMEN Introducción: Los niños en condición crítica, se encuentran en alto riesgo de malnutrición, tanto por sus condiciones preexistentes como por las prácticas nutricionales aplicadas durante la hospitalización, que pueden aumentar el riesgo de morbilidad y mortalidad. Objetivo: Conocer las prácticas de soporte nutricional y los factores que intervienen en la entrega de energía y proteínas en niños con ventilación mecánica. Métodos: Estudio observacional prospectivo con aspectos analíticos, donde se evaluó una cohorte de 40 pacientes con ventilación mecánica (1-17 años) admitidos en la unidad de cuidado intensivo pediátrico del Instituto Nacional de Salud del Niño. Se registraron los datos demográficos y clínicos, se contabilizó el aporte y la adecuación calórica y proteica diaria, las interrupciones en la nutrición, tiempo de estancia, entre otros. Resultados: En el momento del ingreso 70 % presentó desnutrición, 77,5; 12,5; y 7,5 % recibieron nutrición enteral, parenteral y ambas, respectivamente. El inicio del soporte nutricional en promedio fue de 3,5 días. Se alcanzó 24 % de los requerimientos calóricos y 31 % de los proteicos calculados. Las principales causas de interrupción de la alimentación enteral en 39,4 % de las veces, fue el ayuno por intubación o extubación, 24,2 % por cirugía y el 15 % por residuo gástrico elevado. Conclusiones: Se observa alta tasa de desnutrición y pobre adecuación del requerimiento calórico y proteico prescrito. La implementación de un protocolo de nutrición puede facilitar el encargo nutricional del paciente pediátrico en estado crítico.

ABSTRACT Introduction: Children in critical condition are at high risk of malnutrition, both because of their pre-existing conditions and because of the nutritional practices applied during hospitalization, which can increase the risk of morbidity and mortality. Objective: Assess nutritional support practices and factors involved in the delivery of energy and protein in mechanically ventilated children. Methods: Prospective observational study with analytical aspects, where a cohort of 40 mechanically ventilated patients (1-17 years) admitted to the pediatric intensive care unit of the National Institute of Children's Health was evaluated. Demographic and clinical data were recorded; daily caloric and protein intake and adequacy, interruptions in nutrition, time of stay, among others were counted. Results: At the time of admission, 70% presented malnutrition, 77.5; 12.5; and 7.5% received enteral, parenteral and both kinds of nutrition, respectively. The onset of nutritional support on average was 3.5 days. 24% of the caloric requirements and 31% of the calculated proteins were reached. The main causes of interruption of enteral feeding in 39.4% of the time were fasting by intubation or extubation, 24.2% by surgery and 15% by elevated gastric residue. Conclusions: There is a high rate of malnutrition and poor adequacy of the prescribed caloric and protein requirement. The implementation of a nutrition protocol can facilitate the nutritional management of the pediatric patient in critical condition.

Hemangioendotelioma kaposiforme torácico con respuesta favorable a sirolimus. Reporte de caso y revisión de la literatura / Thoracic kaposiform hemangioendothelioma with a good response to syrolimus. Case report and literature review

Se presenta el caso de una niña de 4 meses de edad que ingresa a la Unidad de Cuidados Intensivos (UCI) por presentar el Síndrome de Kasabach-Merritt asociado a un hemangioendotelioma kaposiforme. Luego de un mes de recibir tratamiento con vincristina, corticoides, propanolol y ácido acetilsalicílico, continúa con evolución desfavorable, incrementándose el tamaño de la lesión. Los exámenes de imágenes (tomografia axial computarizada y resonancia magnética nuclear) muestran compromiso de músculos intercostales, pleura, parénquima pulmonar y trombosis de venas cervicales. Posteriormente, llega a presentar cianosis y dificultad respiratoria por obstrucción de vías aéreas, requiriendo intubación y ventilación mecánica. Se inicia sirolimus, y en la segunda semana de tratamiento se evidencia mejoría de la lesión y de la analítica. Se brinda el alta hospitalaria a los 42 días de terapia con sirolimus, tratamiento que continúa recibiendo hasta un año después.

A 4-month girl was admitted to Pediatric Intensive Care Unit (PICU) due to a Kasabach-Merritt Syndrome associated to Kaposiform hemangioendothelioma. After 1-month of treatment with vincristine, steroids, propranolol, and acetylsalicylic acid; her progress was not good, and lesions became larger. Imaging studies (computed tomography and nuclear magnetic resonance) showed involvement of intercostal muscles, pleura, lung parenchyma, and cervical venous thrombosis. Afterwards, the patient developed cyanosis and dyspnea due to an upper airway obstruction, requiring intubation and ventilation support. Sirolimus was started and, on the second week of treatment, both lesion and laboratory parameters improved. The patient was discharged after 42 days of sirolimus therapy. One year later, she is still receiving this drug.

[Etiology of community acquired pneumonia in children 2-59 months old in two ecologically different communities from Peru]. / Perfil etiológico de la neumonía adquirida en la comunidad en niños de 2 a 59 meses en dos zonas ecológicamente distintas del Perú

INTRODUCTION: Community acquired pneumonia (CAP) is a major public health problem, being the most affected the pediatric population. The aim of this study was to compare the etiology, clinical and radiological features of CAP in under- five-year-old children. METHODS: Children have been attended at the Practice or Emergency Room from Puno and Lima health facilities. Twelve pathogens were studied using cultures (bacterial and viral), reaction polymerase chain to S. pneumoniae and H. influenzae, enzyme-linked immunosorbent assay for M. pneumoniae and indirect immunofluorescence test for C. pneumoniae and viruses (nasal and pharyngeal swabs). RESULTS: One hundred and ninety three children were enrolled with clinical and radiological confirmation of pneumonia between July and November 2006. At least one pathogen was identified in 123 (63.7%) of 193 patients. Fifty five percent had viral infection, 21% bacterial infection and 12% presented viral and bacterial co-infection. The most frequent etiologic agents were respiratory syncytial virus (38.3% from all, 69.8% of viral pneumonias) and S. pneumoniae (18.6% from all, 90% from bacterial pneumonias). In Lima, the cases of severe pneumonia predominated. The association of pneumonia with wheezing was reported in Lima, however, it hasn't been reported in Puno. CONCLUSIONS: We found a pathogen in 63.7% of the patients and there were no differences in the proportion and distribution of different identified etiological agents between Lima and Puno health facilities, whose ecological and climatic features are very different. The association of pneumonia with wheezing was only reported in Lima.

Perfil etiológico de la neumonía adquirida en la comunidad en niños de 2 a 59 meses en dos zonas ecológicamente distintas del Perú / Etiology of community acquired pneumonia in children 2-59 months old in two ecologically different communitiesfrom Peru

Introducción. La neumonía adquirida en la comunidad es un importante problema de salud pública y la población pediátrica es la más afectada.El objetivo del estudio fue comparar el perfil etiológico y las características clínico-radiológicas de la neumonía adquirida en la comunidad, en menores de 5 años, en dos zonas ecológicamentedistintas del Perú.Materiales y métodos. Se evaluaron niños atendidos en consulta externa o emergencia de Establecimientosde Salud de Puno y Lima.Se estudiaron 12 patógenos mediante cultivos (bacterianos y virales), reacción en cadena de la polimerasa para S. pneumoniae y H. influenzae,enzimoinmunoanálisis para M. pneumoniae e inmunofluorescenciaindirecta para C. pneumoniaey virus (del hisopado nasal y faríngeo).Resultados. Se incorporaron 193 niños con diagnóstico clínico y confirmación radiológica de neumonía entre julio y noviembre del 2006. Se identificó al menos un patógeno respiratorio enel 63,7 por ciento (123/193) de los pacientes evaluados. El 55 por ciento de las infecciones fueron virales, el 21 por ciento bacterianas y el 12 por ciento coinfección viral y bacteriana.Los agentes más frecuentemente identificados fueron virus sincicial respiratorio (38,3 por ciento del total y 69,8 por ciento entre las neumonías virales) y S. pneumoniae (18,6 por ciento del total y 90 por ciento de las neumonías bacterianas). En Lima predominaron los casos de neumonía grave y la asociación de neumoníacon sibilancias; esta última asociación, no se comunicó en Puno.Conclusiones. Se halló un germen patógeno en el 63,7 por ciento de los casos de neumonía y la proporcióny distribución de agentes identificados fue similar en los centros de Lima y Puno, de características ecológicas y climáticas muy disímiles.La asociación de neumonía con sibilancias sólo fue comunicada en Lima.

Introduction. Community acquired pneumonia (CAP) is a major public health problem, being the most affected the pediatric population. The aim of this study was to compare the etiology, clinical and radiological features of CAP in under-five-year-old children. Methods. Children have been attended at the Practice or Emergency Room from Puno and Lima health facilities. Twelve pathogens were studied using cultures (bacterial and viral), reaction polymerase chain to S. pneumoniae and H. influenzae, enzyme-linked immunosorbent assay for M. pneumoniae and indirect immunofluorescence test for C. pneumoniae and viruses (nasaland pharyngeal swabs). Results. One hundred and ninety three childrenwere enrolled with clinical and radiological confirmation of pneumonia between July and November 2006. At least one pathogen was identified in 123 (63.7%) of 193 patients. Fifty five percent had viral infection, 21% bacterial infection and 12% presented viral and bacterial co-infection. The most frequent etiologic agents were respiratory syncytial virus (38.3% from all, 69.8% of viral pneumonias) and S. pneumoniae (18.6% from all, 90% from bacterial pneumonias). In Lima,the cases of severe pneumonia predominated. The association of pneumonia with wheezing was reported in Lima, however, it hasn’t beenreported in Puno. Conclusions. We found a pathogen in 63.7% of the patients and there were no differences in theproportion and distribution of different identified etiological agents between Lima and Puno health facilities, whose ecological and climatic featuresare very different. The association of pneumonia with wheezing was only reported in Lima.

Riesgo de muerte en la unidad de cuidados intensivos pediátricos: Uso del prism / Risk of death in the pediatric intensive care unit: Prism score

Objetivos: Se realizó un estudio para comparar el desempeño de una Unidad de Cuidados Intensivos Pediátrica (UCIP) y de un puntaje de riesgo de muerte (PRISM) en dos periodos distintos. Material y métodos: Se registró de manera prospectiva la puntuación de PRISM en los niños admitidos a la UCIP del Instituto Nacional de Salud del Niño durante 10 meses. Se analizaron las muertes observadas y esperadas para verificar el desempeño de la UCIP y del PRISM en esta población, luego se procedió a comparar este desempeño con el de un estudio previo en la misma UCIP. Se usó el SPSS para el análisis estadístico. Resultados: Se analizaron 243 pacientes, 122 varones y 121 mujeres. La mediana para edad fue de 13 meses (0.02 - 207) y la mediana de estancia fue 7 días. Las características demográficas de la población del estudio previo no difirieron de la población actual, pero el PRISM en esta última fue menor (11.3 vs. 14.7, p < 0.001), debido a menor frecuencia de niños con riesgo de muerte más alto. La mortalidad en el estudio actual fue menor (21 por ciento vs. 26.1 por ciento), pero la tasa estandarizada de mortalidad (TEM) fue mayor (1.38 vs. 1.26). Hubo diferencias importantes entre la mortalidad observada vs. esperada en los diferentes intervalos de riesgo del PRISM. Conclusiones: En relación a un estudio previo, el desempeño del PRISM desmejoró en relación al estudio previo, y la TEM en la UCIP fue mayor.

Objective: We performed a study to compare the performance of the Pediatric Intensive Care Unit (PICU) and PRISM score in two periods.Material and methods: PRISM score was prospectively registered during 10 months in children admitted to the PICU of National Child Health Institute. Observed and expected deaths were analyzed to evaluate the performance of the PICU and PRISM score. Then we compared this performance with that of a previous study in the same PICU. SPSS was used for statistical analysis. Results: There were 243 patients, 122 male, 121 female. Median age was 13 months (0.02 - 207) and median stay was 7 days. Demographics of population study was similar to the previous one, but PRISM score was lower (11.3 vs. 14.7, p < 0.001), due to a lower frequency of children with higher risk intervals. Mortality was lower in the present study (21 per cent vs. 26.1 per cent), but standardized mortality ratio (SMR) was higher (1.38 vs. 1.26). There were important discrepancies between observed and expected mortality ratios in the different risk intervals of the PRISM score.

Factores de riesgo para infecciones del torrente sanguineo asociados al uso de catéter venoso central en la Unidad de Cuidados Intensivos Pediátricos del INSN / Risk factors for catheter-associated Bloodstream Infections in Pediatric Intensive Care Unit (PICU) of Instituto Nacional de Salud del Niño

Objetivo: Determinar factores de riesgo para las Infecciones del Torrente Sanguineo (ITS) asociados a Catéter Venoso Central (CVC) en pacientes de la Unidad de Cuidados Intensivos Pediátricos (UCIP) del Instituto Nacional de Salud del Niño (INSN).Materiales y métodos: Estudio de cohortes prospectivo en la UCIP deIINSN. Participantes: Pacientes admitidos en la UCIP-INSN entre el1 de junio del 2007 hasta el31 de mayo del 2008. Intervenciones: Ninguna. Medición de resultados: Desarrollo de ITS asociadas al uso de CVC desde la admisión hasta 48 horas después del alta de la UCIP. Resultados: De 183 pacientes, 99 (54 por ciento) fueron masculinos y 84 (46 por ciento) femeninos. La tasa de ITS asociadas a CVC fue 14.03 infecciones por 1000 días uso CVC. Encontramos 24 casos de ITS asociadas a CVC. El Staphylococcus coagulasa negativo fue el germen más frecuente (n=8), seguido de Candida albicans ( n=7). En el análisis de regresión logística, se encontraron los siguientes factores de riesgo: CVC múltiple (mayor que 1) (p: 0.030; RR: 3.2; 95 por ciento IC: 1.1 - 9.2) Y sexo masculino (p: 0.013; RR: 3.1; 95 por ciento IC: 1.3 - 7.7). Conclusiones: Se identificó una alta tasa de ITS asociada a CVC. El sexo masculino y el CVC múltiple (mayor que 1) fueron factores de riesgo para ITS asociados a CVC. Es necesario un estudio prospectivo con mayor número de pacientes para identificar otros factores de riesgo.

Objective: To determine the risk factors for catheter - associated bloodstream infection in Pediatric Intensive Care Unit (PICU) of Instituto Nacional de Salud del Niño. Material and Methods: Design: Prospective cohort study at the PICU of Instituto Nacional de Salud del Niño (Lima - Peru). Patients: PICU patients admitted between June 1, 2007, and May 31,2008. Interventions: None. Outcome measures: Catether - Associated Bloodstream Infections (CABSI) developed from PICU admission until 48 hours after PICU discharge. Results: Of 183 patients, 99 (54 percent) were male and 1 Médico Pediatra Intensivista. Instituto Nacional de Salud del Niño 2 Médico Pediatra Intensivista. INSN. Facultad de MedicinaHumana, Universidad Nacional Federico Villarreal 84 (46 percent) were female. The rate of CABSI was 14.03 infections per 1,000 catheter days. There were 24 cases of CABSI. Coagulase-negative Staphylococcus was the leading causeof CABSI (n=8), followedby Candida albicans ( n = 7). In logistic regression analysis, patients with CABSI were more likely to have multiple central vascular catheter (p: 0.030; RR: 3.2; 95 percent confidence interval: 1.1 - 9.2 ) and be male ( p: 0.013; RR: 3.1 ; 95 percent confidence interval: 1.3 - 7.7).Conclusions: This study identified a high rate of CABSI. Male sex and multiple CVC (major that 1) were risk factors for Catheter-Associated Bloodstream Infections (CABSls). A prospective study with more number of patients is needed to identify other risk factors.

Burnout (desgaste profesional) en el peediatra / Burnout in the paediatrician

El síndrome de burnout es una patología descrita fundamentalmente en profesionales que trabajan con personas y cuya labor demanda compromiso emocional, despersonalización y falta de realización personal, siendo el más importante el agotamiento emocional. Los médicos y especialmente los pediatras, estamos particularmente expuestos al burnout. Alrededor del 30 por ciento de pediatras sufrimos del problema. Existen múltiples factores que favorecen su presencia, dentro de los cuales se encuentran el tipo de personalidad, factores históricos y culturales, y factores organizativos. El tratamiento y la prevención del burnout deben incluir aspectos pertenecientes a estos factores.

Burnout syndrome is described in professionals who deal with human beings, whose work demand emotional compromise. The three dimensions of the syndrome are emotional exhaustion, depersonalization and lack of professional achievement. Physicians, particularly paediatricians, are at an increased risk for the development of burnout. It is present in approximately 30 per cent of paediatricians. Several factors influence its devlopment, like type of personality, historic and cultural factors, and organnization's factors. Prevention and treatment of burnout should involve these factors.

Hiperglicemia y mortalidad en niños críticamente enfermos / Hyperglycemia and mortality in critically sick children

Se realizó un estudio de cohorte histórica para determinar si la hiperglicemia a la admisión se asocia a mortalidad. Ingresaron al estudio todos los pacientes admitidos a la Unidad de Cuidados Internsivos Pediátricos (UCIP) desde diciembre del 2001 hasta junio del 2005, con datos sobre glicemia, puntuación de PRISM (Pediatric Risk of Mortality) y su desenlace final. Todos los datos fueron colectados de manera prospectiva. Se consideró como grupo control (normoglicemia) los valores de glicemia entre 60 - 126 mg por ciento y grupo de estudio (hiperglicemia) los valores menor que 126 mg por ciento. La mortalidad fue la acaecida durante la estancia en la UCIP. Se utilizaron diversas pruebas estadísticas para investigar la asociación entre glicemia y mortalidad. Se incluyeron 939 pacientes para el estudio, 523 varones y 416 mujeres. La edad promedio fue de 44.54 meses (0.02 -207), la mediana de estancia fue de 6.45 días y el promedio de PRISM fue 12.25 (0 - 49). La mortalidad global fue 19.5 por ciento. El nivel de glicemia promedio fue 144.55 vs. 172.07 mg por ciento en los sobrevivientes y fallecidos, respectivamente (p menor que 0.05). Se encontró hiperglicemia en 428 casos (45.6 por ciento) y 442 casos (47.1 por ciento) pertenecieron al grupo control (normoglicémicos). La mortalidad en el grupo de hiperglicemia fue mayor que la del grupo control (21.7 por ciento vs. 15.4 por ciento; p menor que 0.05), con un RR 1.41 (IC: 1.06, 1.87). El PRISM fue mayor en el grupo de hiperglicemia, al igual que la edad. Conclusiones.- 1) La hiperglicemia es frecuente al momento de la admisión en nuestra UCI, 2) La hiperglicemia está asociada a mayor riesgo de muerte.